The BridgeWay
501-771-1500

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Patient Referral Form




Date: By:   
REFERRING THERAPIST:
Name:
Full Address:
City:
State: Zip:  
Phone: Fax: 
PATIENT INFORMATION:
Name:
Age: Admit Date Requested: 
Type of Insurance/Pay arrangements? 
Estimated LOS:
PRESENT SYMPTOMS:
 depressed mood
 anxiety
 panic attacks
 sleep disturbance
 appetite disturbance
 inability to function
 poor concentration
 decreased energy
 hopelessness
 helplessness
 anrgy/rageful
 suicidalidealtion
 suicide plan(s)
 past suicide attempt (s)
when?

how?

 psychotic
 other:
 flashbacks
 nightmares
 isolative behavior
 dissociative episodes
 loss of time
 memory loss
 self-harming behavior
what?

 eating disorder
 compulsive overeating
 restricting
 binging
 purging
how?

laxatives?

 weight gain
 weight loss
how much?
 relationship problems
 affairs
 use of prostitutes
 use of pornography
 anonymous sex
 Internet sex
 voyeurism
 exhibitionism
 compulsive masturbation
 other acting out behavior(s):

 alcohol/drug abuse
 sexual identity issues
 compulsive spending
 compulsive gambling
 low self-esteem/worth
 legal issues
what?
TRAUMA HISTORY:
MEDICAL PROBLEMS: (Describe)
MEDICATIONS:
PAST TREATMENT:
SPECIAL NEEDS (diet, wheelchair, hospital bed, physical/respiratory thrapy, etc.)
ADDITIONAL PERTINENT INFORMATION:
INPATIENT TREATMENT GOALS: